AAPC-CIC Certified Inpatient Coder - Set 1 - Part 1

Correct Answer: No more than 30 days

The hospital record requirement says a medical history and physical examination must be completed and documented no more than 30 days before, or 24 hours after, admission or registration, and prior to surgery or a procedure requiring anesthesia services. Option a is incorrect because the regulation sets a longer pre-admission window than this, so a 7-day limit understates what is permitted and does not match the stated rule. Option b is incorrect because this interval appears nowhere in the record-content requirement, which gives a different time limit before admission and a separate one after it. Option d is incorrect because 24 hours is the window after admission or registration for completing and documenting the examination, not the allowance for work done beforehand.

Correct Answer: Medical record number

For deaths recorded in the internal log or other system, 42 CFR 482.24 requires each entry to document the patient's name, date of birth, date of death, responsible practitioner, medical record number, and primary diagnosis(es). Option b is incorrect because the rule requires primary diagnosis(es) in the entry, not a separately stated cause of death, so this is a different data element. Option c is incorrect because the entry names the attending physician or other licensed practitioner responsible for care; family contacts are not part of the required log content. Option d is incorrect because the regulation does not list it among the required log elements, which center on identifying the patient and the death rather than the stay's start.

Correct Answer: Author identification and record maintenance system

The Medicare condition of participation requires a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. Option a is incorrect because coding and indexing exists so records can be retrieved promptly by diagnosis and procedure for medical care evaluation studies, not to confirm who authored an entry. Option b is incorrect because this procedure limits release of record information to authorized individuals and blocks unauthorized access or alteration, rather than establishing the identity of each entry's author. Option d is incorrect because staffing under the organization standard concerns adequate personnel for prompt completion, filing and retrieval of records, and it does not address authentication of entries.

Correct Answer: Confidentiality of patient records

The Confidentiality of patient records standard gives the patient the right to the confidentiality of clinical records and the right to access medical records, including current ones, on an oral or written request. Option b is incorrect because this is a separate standard that deals with freedom from physical or mental abuse; it does not set out how a patient obtains record access. Option c is incorrect because this standard covers personal privacy, care in a safe setting and freedom from abuse or harassment, and it does not address access to medical records. Option d is incorrect because this right lets the patient formulate directives and have staff comply with them, which is a different subject from obtaining copies of the record.

Correct Answer: Standing order

The inpatient admission order cannot be a standing order. Only the ordering practitioner, or a resident or other practitioner acting on his or her behalf, may furnish it, with authentication where required. Option a is incorrect because practitioners without admitting privileges but authorized by the hospital may issue these orders, using the same countersignature process by the ordering practitioner. Option b is incorrect because staff who lack admitting authority may transcribe it at the time received, provided the ordering practitioner is identified and countersigns promptly, before discharge. Option c is incorrect because the ordering practitioner may let a resident write the order on his or her behalf, accepting responsibility by authenticating it prior to discharge.

Correct Answer: Identity of the individual providing the service

OIG guidance states that documentation supporting claims should record the length of time spent in the activity leading to the record entry and the identity of the individual providing the service. Option a is incorrect because daily billing volume is not an element the guidance asks documentation to record; it concerns support for each claimed service. Option b is incorrect because reimbursement rates are not listed by OIG guidance as documentation content; the guidance names time spent and the identity of the person providing the service. Option d is incorrect because coder compensation is addressed separately, as a matter of avoiding financial incentive to upcode, and is not an element of service documentation.

Correct Answer: An updated examination

When the medical history and physical examination is completed within 30 days before admission, an updated examination, including any changes in the patient's condition, must be completed and documented within 24 hours after admission and prior to surgery. Option b is incorrect because an assessment replaces the history and physical only for specific outpatient surgical or procedural services, not for a patient admitted as an inpatient. Option c is incorrect because a discharge order concerns the end of the stay and the effectuation of discharge activities, not the pre-surgical examination requirement. Option d is incorrect because the rule accepts a history and physical done within 30 days before admission, so repeating it is not required; only an update is.

Correct Answer: Signing and dating of the attending physician's acknowledgement

The physician acknowledgement is a separate requirement: the hospital must have a signed and dated statement from the attending physician on file when a claim is submitted. It is not among the QIO review items. Option a is incorrect because the QIO also reviews the completeness, adequacy, and quality of services furnished in the hospital, so this belongs among the listed review areas. Option b is incorrect because the validity of the hospital's diagnostic and procedural information is expressly named as a QIO review item, which makes it a member of the set. Option c is incorrect because the QIO review list begins with the medical necessity, reasonableness and appropriateness of hospital admissions and discharges, so it is a listed review item.

Correct Answer: Disregard the missing signature and continue the review

When no statute, regulation, NCD, or LCD requires a signature and it is not needed to identify the author, the contractor disregards the missing or illegible signature and continues reviewing all documentation for coverage, coding, and billing requirements. Option a is incorrect because denial for a signature problem follows an unresolved required signature or authenticity concern; without either, the missing signature is not a basis for denial. Option b is incorrect because attestation is reserved for cases where a signature requirement is unmet or authenticity concerns exist, and neither condition applies here. Option d is incorrect because referral belongs to cases where the totality of the record raises concerns about legitimacy or falsity, which this record does not show.

Correct Answer: Each patient at the time of registration

The training standard applies to members of the covered entity's workforce: existing members, new members, and those affected by a material change in policies. Patients are not workforce members, so training them is not required by this standard. Option a is incorrect because a material change in policies or procedures triggers retraining for affected members within a reasonable period after the change takes effect. Option b is incorrect because new workforce members must be trained within a reasonable period of time after the person joins the covered entity's workforce. Option c is incorrect because the rule requires training for every member of the workforce by no later than the compliance date for the covered entity.

Correct Answer: at the time they are rendered

The Medicare manual expects all services provided to beneficiaries to be documented in the medical record at the time they are rendered. Amendments, corrections and delayed entries are the occasional exceptions and must be identifiable. Option b is incorrect because claim signing is not the trigger the manual names; documenting after the claim would resemble a delayed entry, which is the exception. Option c is incorrect because the manual sets no billing-cycle deadline for documentation; it expects entries when the service occurs rather than when billing is processed. Option d is incorrect because the manual ties the expectation to the moment of service, not to an audit, and says nothing about waiting for review.

Correct Answer: UPIC

Under the Medicare guidance on potential fraud referrals, suspected fraud found at any time shall result in a referral to the UPIC for development. MAC, RAC, SMRC and CERT reviewers are the referring reviewers. Option a is incorrect because the guidance groups it with reviewers who find missing or illegible signatures, rather than naming it as where suspected fraud goes for development. Option b is incorrect because the guidance lists RAC reviewers with those who spot signature problems raising legitimacy or falsity concerns; it does not name RAC as the recipient of fraud referrals. Option c is incorrect because its reviewers are among those who identify missing or illegible signatures and consider referring concerns, which places it on the referring side, not the receiving side.

Correct Answer: I, II, and III

The Medicare manual says the date and author of any amendment, correction or delayed entry should be identifiable, and the change should be clearly and permanently denoted. It also allows entries after the service is rendered, so IV is false. Option b is incorrect because it leaves out statement III, yet the Medicare manual also expects the change or addenda to be clearly and permanently denoted in the record. Option c is incorrect because it relies on statement IV, which is false; the manual recognizes that documentation may be entered after rendering the service, and it also drops the date requirement. Option d is incorrect because statement IV contradicts the manual, which allows a delayed entry after the service, and this choice omits the expectation that the author be identifiable.

Correct Answer: The covered entity must allow submission of the statement, including the basis of the disagreement.

Under the HIPAA amendment standard, a covered entity must permit the individual to submit a written statement disagreeing with the denial of all or part of a requested amendment, along with the basis for the disagreement. Option a is incorrect because the rule covers a denial of all or part of a requested amendment, so a partial denial still entitles the individual to submit a statement. Option b is incorrect because the written denial itself informs the individual of the right to submit a statement and how to file it, so the statement follows the denial. Option c is incorrect because a rebuttal is optional; the covered entity may prepare one, but nothing obliges it to respond to the statement.

Correct Answer: Append the amendment or link to its location

Under the HIPAA amendment standard, accepting a request requires the covered entity, at a minimum, to identify the affected records in the designated record set and append the amendment or provide a link to its location. Option a is incorrect because patient agreement is tied to notifying relevant persons who need the amendment, which is the informing step, rather than the way the amendment is made. Option b is incorrect because a written denial is the required response when a requested amendment is refused in whole or in part, and here the amendment was accepted. Option d is incorrect because that statement belongs to the one permitted extension of time, used when the entity cannot act within the required period; it does not make the amendment.

Correct Answer: A registered nurse, social worker, or other appropriately qualified personnel

The Medicare condition of participation requires any discharge planning evaluation or discharge plan to be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel. Option a is incorrect because the regulation does not assign the evaluation to this role; it names qualified clinical or social service personnel to develop or supervise it. Option b is incorrect because the representative takes part by receiving the discussion of the results, but does not develop or supervise the evaluation itself. Option c is incorrect because a post-acute provider is selected with the hospital's help using shared data; nothing places development of the evaluation with that provider.

Correct Answer: Hospice services at all levels of care

The ICD-10-CM Official Guidelines state that UHDDS application expanded to all non-outpatient settings and that the definitions also apply to hospice services at all levels of care. Option a is incorrect because the guidelines extend the UHDDS definitions to non-outpatient settings, and a physician office visit is an outpatient encounter, so it falls outside that expansion. Option c is incorrect because outpatient services are excluded from the expanded scope, which covers only non-outpatient settings, so same-day surgical encounters are not governed by these definitions. Option d is incorrect because these centers deliver outpatient care, whereas the UHDDS definitions were extended to settings such as nursing homes, rehab facilities, and home health agencies.

Correct Answer: The coder

The PCS conventions state it is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions. A query is not required when the correlation is clear. Option b is incorrect because the physician is not expected to use the terms found in PCS code descriptions, so the correlation to defined terms is not the physician's task. Option c is incorrect because the conventions place responsibility for correlating documentation with PCS definitions on the coder, and they do not assign that responsibility to an auditor. Option d is incorrect because the conventions describe documentation in the medical record and the coder's correlation of it to PCS definitions; they give the patient no part in that step.

Correct Answer: The provider

The guidelines state that the listing of the diagnoses in the patient record is the responsibility of the provider, meaning the physician or qualified health care practitioner legally accountable for establishing the patient's diagnosis. Option a is incorrect because hospital policy may require coding certain resolved conditions, but a policy is not a person and does not list diagnoses in the record. Option b is incorrect because the coder assigns codes from the documented diagnoses; the guidelines place the listing of diagnoses in the record with the provider, not the coder. Option c is incorrect because these four organizations approve the guidelines themselves, so their role is to issue official rules rather than to document a patient's diagnoses.

Correct Answer: Assign the default code

A condition documented without additional information, such as acute or chronic, receives the default code. The default code is listed next to the main term in the Alphabetic Index and is the most common or unspecified code. Option a is incorrect because code assignment rests on the provider's diagnostic statement, not on the clinical criteria used to establish it, and nothing here conflicts. Option c is incorrect because codes are reported to the highest specificity documented in the record, and this record documents no acuity, so no more specific code is supported. Option d is incorrect because a three-character code is used only when the category is not further subdivided, so a subdivided category needs its full characters.